John H. Gibbon

PROBLEMS IN HEMOSTASIS WITH EXTRACORPOREAL APPARATUS.

When an extracorporeal circulation is employed, the patient’s blood must be rendered incoagulable with heparin. This necessary state of incoagulability may become a serious threat to the life of the patient. Postoperative difficulty with hemostatis when an extracorporeal apparatus has been used is not uncommon. A surgeon performing open-heart operations must, therefore, be prepared to deal with an occasional difficult problem of continued postoperative bleeding. A single simple defect in the coagulation mechanism may be present which can be quickly and easily corrected. On the other hand, there may be multiple defects in the coagulation process, making the task of restoring normal coagulability complex and difficult. Finally, the worst problem of all is when the hematologist has performed every test on the patient’s blood known to his esoteric a r t and reports: “Nothing is the matter with the patient’s blood except that it won’t clot.” We will assume in the following discussion that preoperatively there was no hematologic disorder and no abnormal capillary fragility. We shall also assume that there has been no incompatibility between the blood in the circuit, the blood transfused during the operation, and the patient’s blood. Trauma to the blood is probably the most important factor in the development of a bleeding diathesis af ter employing an extracorporeal blood circuit.11 The concentration of free hemoglobin in the plasma is a rough index of the degree of trauma to the erythrocytes, and hence to other components of the blood. I t is not a quantitative index of the amount of hemolysis, however, as the free hemoglobin in the plasma is continually being removed by the kidneys. However, the greater the observed hemolysis, the greater the chance that a bleeding diathesis will develop. Since the degree of trauma to the blood with any extracorporeal apparatus varies directly with the duration of the perfusion, patients who have had long perfusions are more likely to bleed postoperat‘ively.” Extracorporeal blood circuits should be designed to diminish trauma to the blood caused by excessive turbulence. “Jet effects,” passage of blood at high speed from a narrow conduit into a wide one, a r e particularly injurious to the cellular elements of the blood and should be avoided. Return of blood from the patient to the extracorporeal apparatus by the so-called “coronary-sucker” system may injure erythrocytes, especially if large amounts of a i r are aspirated with the blood.“

The surgical treatment of carcinoma of the lung

Abstract A brief analysis of a series of 617 patients with cancer of the lung is presented. The results of surgical treatment are reported and the technic of radical pneumonectomy described.

Current status of pump oxygenators in cardiac surgery and persistent problems in their use

Summary We have attempted to outline, and critically discuss, the varieties of pumpoxygenator systems which are currently in existence. We have placed more emphasis on those which are most widely used or considered by us to be the safest to employ in surgical operations. We believe that the membrane-type oxygenator, with its completely closed system, holds great promise for the future. Certain basic problems in the use of these extracorporeal blood circuits have been solved. Hemolysis, embolic phenomena and infection fall into this category. The problem of postoperative pulmonary edema is lessening. The safety of elective cardiac arrest is being widely studied. The relation of metabolic acidosis to low perfusion rates, we believe, has been adequately documented. The many new surgical technical problems which have arisen with the use of cardio-pulmonary bypass are being studied in many centers and much progress should be made in the next few years in this field. Finally, the cost of pump-oxygenators, in money, personnel and blood should see a considerable decline.

Advantages of a tracheotomized anesthesia technic in the pharyngeal flap operation.

Abstract 1. 1. A tracheotomy anesthesia technic as a technical aid to the pharyngeal flap operation is discussed. 2. 2. Over fifty pharyngeal flap operations are evaluated, and the technic of the flap application is described. 3. 3. The advantages and disadvantages of this technic are reviewed.

The Inquiring Mind.

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FURTHER EXPERIENCE WITH ANEURYSMORRHAPHY (MATAS): A REPORT OF EIGHT CASES

The year 1902 marks the beginning of a new epoch in the treatment of aneurysms for it was at this time that Matas presented to us a description of what is now generally called the Matas operation and reported four cases on which he had successfully operated. This presentation was made before the American Surgical Association. 1 The account of his first case, one of aneurysm of the brachial artery, is extremely interesting as it shows how the idea originated of curing the aneurysm by suture from within the sac of all arterial openings. In this case several of the older methods of compression had failed, later ligation after the manner of Anel failed and still later distal ligation failed. Matas then opened the sac and discovered that the failure of the previous ligations was due to the entrance of blood into the sac through one or two large collaterals.

CECAL HERNIA WITH A CLASSIFICATION OF SIXTY-THREE CASES.

My attention was turned to the subject of cecal hernia by a case which occurred in the service of Dr. T. S. K. Morton at the Polyclinic Hospital about two years ago and later by another upon which I saw Dr. Richard H. Harte operate at the Pennsylvania Hospital, and it is due to the kidness of these gentlemen and of others who have allowed me the use of their unreported cases, that I am enabled to make the following report. By looking up the literature of this variety of hernia and by making inquiries among operators largely experienced in herniotomy, I have been able to collect and classify sixty-three cases, and from them draw certain conclusions which I trust may prove of interest. In the appended table of cases I have only included the inguinal and femoral varieties of hernia, and of these only such as have been proved